Form Dexm - Domestic Companies Annual Report - 2012
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5DEXM (12-12)
STATE OF NEW JERSEY
2012
DOMESTIC COMPANIES
Insurer NAIC Code Number
Type or print the requested information
FEDERAL EMPLOYER I.D. NUMBER
Insurer NAIC Group Code Number______________
COMPANY NAME
MAILING ADDRESS
IMPORTANT:
THE FOLLOWING INSTRUCTIONS
MUST BE ADHERED TO:
CITY
STATE
ZIP CODE
The Original Return must be filed with the Director, Division of Taxation
on or before March 1 annually and shall be
accompanied with a CHECK PAYABLE TO - " NJ DIVISION OF TAXATION -- INSURANCE TAX"
PLEASE REFER TO THE INSTRUCTIONS CONCERNING ELECTRONIC FUNDS TRANSFER (EFT) PAYMENTS.
Mail to:
Division of Taxation
PO Box 247
(160 South Broad Street)
ALSO
Trenton, NJ 08646-0247
A duplicate return must be filed with the Commissioner of Banking and Insurance at the same time.
Mail to:
Department of Banking and Insurance
PO Box 325
(20 West State Street)
Trenton, NJ 08625-0325
WHEN COMPLETING THIS RETURN, PLEASE BE SURE TO FOLLOW THE GENERAL FILING INSTRUCTIONS ON PAGE 4.
ANNUAL REPORT
Statement of Premium Taxes and Other Obligations
Life Insurance Companies
Commissioner of Banking and Insurance, State of New Jersey :
Director, Division of Taxation, State of New Jersey :
The
incorporated or organized under the laws of New Jersey and with offices located at
MAILING ADDRESS OF OFFICE PREPARING RETURN
hereby submit the following statement for the calendar year ending December 31, 20
, as required by, and in accordance
with the New Jersey Revised Statutes Title 54 chapters 16, 17, 18 and 18A.
The actual address of the New Jersey Principal Office:
STREET, CITY, ZIP CODE
, which is located in
NAME OF MUNICIPALITY* AND COUNTY
*Please be sure to indicate the actual municipality and not the New Jersey mailing address.
Date of Incorporation or organized
Date first licensed in New Jersey
STATE OF
}
ss.
COUNTY OF
On this
day of
A.D. 20
before me
personally appeared
(INSERT SECRETARY OR U.S. MANAGER)
Insurance Company of
who being duly sworn according to law, on his oath did depose and say that the foregoing report is true and correct.
Subscribed and sworn to before me the
day and year aforesaid.
(INSERT SECRETARY OR U.S. MANAGER)
IMPORTANT:
THIS BLOCK MUST BE COMPLETED
FEDERAL EMPLOYER IDENTIFICATION
NUMBER
(OFFICIAL TITLE)
(NAME OF PARTY TO CONTACT REGARDING THIS RETURN)
(TITLE)
(PHONE NUMBER)
(FAX NUMBER)
(SIGNATURE OF INDIVIDUAL PREPARING THIS RETURN)
(PREPARER'S IDENTIFICATION NUMBER)
(NAME OF TAX PREPARER'S EMPLOYER)
(EMPLOYER'S IDENTIFICATION NUMBER)
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